For frail, elderly patients with large impacted common bile duct (CBD) stones, long-term treatment with biliary stenting provides palliation. Biliary stenting with choleretic agents such as ursodeoxycholic acid (UDCA) and terpene preparations may promote CBD stone size reduction. We studied the effectiveness of biliary stenting combined with UDCA and a terpene preparation as a medical treatment for difficult-to-remove CBD stones in patients older than 65 years in this multicenter, prospective study.
A total of 28 elderly patients with CBD stones refractory to conventional endoscopic removal, including mechanical lithotripsy, underwent endoscopic placement of a straight 10-F plastic biliary stent. Each patient was administered 600 mg of UDCA and 300 mg of a terpene preparation daily for a mean of 6 months. After 6 months of medication following the initial endoscopic retrograde cholangiopancreatography (ERCP), a second ERCP was performed and endoscopic stone removal was again attempted. Differences in stone size and CBD diameter before and after biliary stenting and medication were compared. The complete stone removal rate after treatment was obtained.
The mean size (transverse × longitudinal diameter) of the CBD stones was initially 21.6 × 29.5 mm, and it decreased significantly to 12.2×20.1 mm at the second ERCP (P<0.01). The mean CBD diameter measured initially at the cystic duct insertion level was 23.2 mm, and it decreased significantly to 19.5 mm at the second ERCP (P<0.01). After biliary stenting with medication, endoscopic stone removal was successful in 26 of 28 patients (92.8%), with a mean of 1.7 subsequent ERCP sessions.
Endoscopic biliary stenting with a period of combined UDCA and terpene preparation administration seems to be a safe and effective method for retained CBD stones in elderly patients. A prospective study with randomization and a control group is required to confirm these results.
Am J Gastroenterol 2009; 104:2418-2421; doi:10.1038/ajg.2009.303; published online 30 June 2009
1Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, South Korea; 2Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, South Korea; 3Department of Internal Medicine, Inha University College of Medicine, Incheon, South Korea.
Correspondence: Jong Ho Moon, MD, PhD, Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Digestive Disease Center, Soon Chun Hyang University Bucheon Hospital, 1174 Jung-Dong, Wonmi-Ku, Bucheon 420-767, Korea. E-mail: firstname.lastname@example.org
Received 19 February 2009; accepted 22 April 2009